I I

of Public visit

Complaint CA00200378

Representing the

event investigated findings

Health A clinic hospice

unauthorized patients subd v sion and

I

or disclosed hundred occurrence use information

tnformed

Event 10YRJL 11

J r-cCtJ i9LLO

CALIFORNIA HEALTH AND HUMAN SERVICES AGENCY DEPARTMENT OF PUBLIC HEALTH g v STATEMENT OF DEFICIENCIES PltOVIOERISUPPLIERICUA

AND PLAN OF CORRECTION IOENTIFlA liON NUMBER

050180

(X1) (X1)11ULTIPLE CONSTRUCTION (XJ) DATE SURVH

COMPLETED

A BUILDING

B MNG 062912010 I NAhiE OF PROVIDER OR SUPPLIER

John Muir Medical Canter- Walnut Creek

Campus

STREET ADDRESS CITY STATE ZlP CODE

1601 YGNACIO VALLEY ROAD WALNUT CREEK CA 94598 CONTRA COST A

COUNTY

(X4)1D SUhiWRY STATEUENT OF OEFIGIEHCIES

(EACH DEFICIENCY MUST BE PRECEEDEO BY FULL REGUtATORY OR LSC IDENTIFYING INFORWTION)

m

The following reflects the findings of the Department Health during a complaintlbreaGh event

Intake Number

bull Substantiated

Department of Public Health

HFEN

The inspection was limited to the specific facility

and does not represent the

of a full inspection of the facility

ood Safety Code Section 128015(8)

health facility home health agency Olt

licensed pu rsu ant to Section 1204 1250

1725 0lt 1745 shall prevent unlawful 0lt

access to aod ooe or d isclosu re of

medical informat ion d efined

i i (g) of Section 5605 of the Cilil Code

consisten t with Section 130203 The

department a tfer investigation may assess eo administrative pe nalty for a violation of this sect ion

of up to twenty-five thousand dollars ($25000) per

pat ient whose medical infermation was unlawfully

without authoriza t ion accessed used 0lt aod to seventeen thousand f1ve

dollars ($17500) subsequ ent of unlawful 0lt u nauthorized access

0lt disclosure of that patients medical

The hospital detected the breacn 00 81109 and

the Depa rtment within the requ ired five

business day time period

73012010

OR PROVIDERSUPPLIER REPRESEHTAnVES SIGNATURE

PROIlOERS PLAN OF CORRECTION

(EACH CORRECTIVE ACTION SHOULD BE CROSS

REFERENCED TO THE APPROPRIATE DEFICIENCY) PREFIX PREFIX

COioiPLETE

om

Plan of Correction Response for Complain II CA00200378

To ensure cDrreclion was accomplished both temporarily and p ermanen tly for each the following actions have been taken

1 Patient go and Wife notified via US mail

of incident and offered credit monitoring protection service

81709

Responsible Person VP Chief Compliance and Privacy Officer

2 Implemented new process for management of the Emergency

Departmen t Patient Information Sheets which requires that clerks immediately scan and shred informat ion sheets upon receipt from the patient This new proces s will provide additional safeguards to further protect patien t information from unauthorized access use or discJosu re

99og

Responsible Person Office Manager Emergency Departmen t and Director Emergency Department 915109 amp

91709

3 Reviewed and educated Clerical Staff on neYJ process Responsible Person Office Manager Emergency Department

91044AM

TJTIE (XB) DATE

ant ending wilt1 an Hlerisk () deiIOUs a defiCiency which lha lnstHulloll may be excused rrcm conecllng prcvkllng il is dete1111ined that other salegua s provide suffident pralecllon D the pallenls Excaptfor nunlng homea the findings above are diulosa lil iKI days following Ole dalo ct SUMY whether or not a plan of correcOOn is provldld For nuning horn$ the above findings and plans or coiEICkln are disclo8able 14 days following 1t1111 dale these documents are made eveila e 1o he facility 1r dllllclsnles are cited an appro ed plan or correclion Ia requisite lo continued pnrem

parliclpabon

5tata-2567 1 of 5

j

---------middotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddot---------------middotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddot-----

CALIFORNIA HEAllr AND HUMAN SERVICES A3ENCY

DEPARTMENT Of PVSUC HEALTH

STAEiolEkTOF OEFIC-lgtCIES 0(1) PROIIDERbullSIJPPUEIClgtli (lt2) loULf1PLE CONSTRUCTION (XJ) 01 TE SURWY i00 HA (pound CQRtJCQltl I JEt lFICAflON tU 9ER CltmlllThJ

A_ euJbullOINC

BMNG 0611Ui2010

MC OF PPOYIOEIlt OR SfifUER STREETAOJRESS CIT STATI- ZIP CODE

John Muir Medlesl CentermiddotWalnut CrMk 1601 YGNACIO VALLE( ROAD WALNUT CREEK CA 9468$ COHTRA COSTA

-middot COUNTY

txbullliD SUMWltY STA T OF OEFICENCIES

EACi lEFIIECY US BE PRECeuroeuroCED BY FiJLL ilEGIO-m_y OR eSC liJ Et41 fYIIIC NfORIIATION)

Continued From paga 1

B01$ed on oCoervOJiion lnteMew coed nowiew I hospfal raed tc $Sfeguard the informalion in IPallen SOs 1nedical record by faling to protect the

Eneqerny Department Patient lnformelion Sheet

resufting 1n 1he ide1tity theft of patient and his wife

Findings

Oc 5120110 Assistant Compli ance Officer

p esented review the hospital Privacy Breach fnwstlgation Form fhe br each n the

confidentiality ot Patient 90s medi cal info rrJaUon The Privacy Breach Investigation Form dated 81709 inc lu ded the Incident Report Fo eight pages document showed hat Palie1t

90s wife called the hosptal on 81109 lo report lhflt sha hd been the oJictim of idert(ity thet lhal the person 1amp5pOMibamp (Of this crirramp hgt Of he possesson at the time of arrest heaOh

informfllion from the hospital wich she used o

commit fraud

Further review showed that P tient 90 wife brought Patient 9tllo ED iEilergtrtt Department e 01 p t gtr of there

I

gisration orocess he wife middot- the

hoepttal term Nted [rloep tal narre) Emergency CWpartrnent Patient Information Sheei and provided Patent 90 and Cf ( was tho primltry insured) pampl$011amp hformllJo inclJdng t full

na E$- datQs ol birth address end social security

numbers Pa1ier 90was admitted arnl later

discharged The wife tlto eeited lh within a few

weeks after Patinl 90s clschage from

PIOVIOEASAN OF COIFiCTOIW (- ) (ACtgtcORREC1-EACT ON SH-U O SE C OSS- COMgtE_ E

IltElEiICNC10 TO THE APPRO FiAT5 lEFCIENC IltEHX PREFIX I

fAG

Continue Phm of Correction Response for Complaint CA0020037$

4 lmpmiddoteme11 rew process for closJre Of B9110 podmiddot by cenca staff members wilhmiddot1 the Emerge cy DeoartmeL t-ew

process requires that prlomiddot to a p00closure all paUenl re a led cocumentatior nor--paient inforrraon sheets wll be p1yscally moved by he aoprcpfiale cerk lc =-oo 3 Which 1s always cccupied by a derical staff nemcer_ Tt-is 1ew processw further safegJard oatie11 hfurmalcn maintained by cmiddotefieal staffWJhin the Errergrocy Departner

Responsible Perton Office Manager

Erlergexy Deoartment

5 Jaily eiiew concucted three times per

day (eacl shift) in a 24-hcur period ro ampW20i0

ensure Cleflos complmnce hilh (on-gorgtg

cepartmeot procedure for scanning and for a periOd

shredding patienl1nformaUon sheeis d 30 C3j5)

Review o continue for a period of 30

days to ensJre 100 compliarce with department procedure Appropriate

acliar to be taken 11 accordance with review lindmgs Review to be re-evaJated after 30 days to ascertalr wheher moniortng will be conllnJeltJ discontinued ot revised

Rl$JgtOO$ibl P8rsQO Office Marbullaer Emergency Department and lead CleO Emergency Department

1i lho

I

81errti0YR3L 1 TITLE (X6)WTE

An defklency ttablmerri erdlgtJ Jib bull - ut IW 11 de a dllfoilttey tkh IM irlllttllbon may boo ud lrorn auwf pmWinl A daiSfTineo trial oltllaquo VlfeJMJIIt proVIde bullIJI)Imiddotenl p m 1M plliefW fotlliiAI9 hciM4 1M fWmgt bullgtwoo AalampqgtJa(IID to dllfi diowig bull dam QligtNuy wlgtelherlaquo rct11 rllill or em _ lllaquoriltkd For lliiiWlP lhit flrntmnamp iillll plmllof regn- ere 4JtimlttgtQ j-4 leloewirll 1t1a date teso doerotfltr ao mado ayenQbe b le aQty_ lf tile an a pill d COIledion s requilamp tn llfued am PifcipampIXfl

j

---------middotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddot---------------middotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddot-----

CALIFORNIA HEAllr AND HUMAN SERVICES A3ENCY

DEPARTMENT Of PVSUC HEALTH

STAEiolEkTOF OEFIC-lgtCIES 0(1) PROIIDERbullSIJPPUEIClgtli (lt2) loULf1PLE CONSTRUCTION (XJ) 01 TE SURWY i00 HA (pound CQRtJCQltl I JEt lFICAflON tU 9ER CltmlllThJ

A_ euJbullOINC

BMNG 0611Ui2010

MC OF PPOYIOEIlt OR SfifUER STREETAOJRESS CIT STATI- ZIP CODE

John Muir Medlesl CentermiddotWalnut CrMk 1601 YGNACIO VALLE( ROAD WALNUT CREEK CA 9468$ COHTRA COSTA

-middot COUNTY

txbullliD SUMWltY STA T OF OEFICENCIES

EACi lEFIIECY US BE PRECeuroeuroCED BY FiJLL ilEGIO-m_y OR eSC liJ Et41 fYIIIC NfORIIATION)

Continued From paga 1

B01$ed on oCoervOJiion lnteMew coed nowiew I hospfal raed tc $Sfeguard the informalion in IPallen SOs 1nedical record by faling to protect the

Eneqerny Department Patient lnformelion Sheet

resufting 1n 1he ide1tity theft of patient and his wife

Findings

Oc 5120110 Assistant Compli ance Officer

p esented review the hospital Privacy Breach fnwstlgation Form fhe br each n the

confidentiality ot Patient 90s medi cal info rrJaUon The Privacy Breach Investigation Form dated 81709 inc lu ded the Incident Report Fo eight pages document showed hat Palie1t

90s wife called the hosptal on 81109 lo report lhflt sha hd been the oJictim of idert(ity thet lhal the person 1amp5pOMibamp (Of this crirramp hgt Of he possesson at the time of arrest heaOh

informfllion from the hospital wich she used o

commit fraud

Further review showed that P tient 90 wife brought Patient 9tllo ED iEilergtrtt Department e 01 p t gtr of there

I

gisration orocess he wife middot- the

hoepttal term Nted [rloep tal narre) Emergency CWpartrnent Patient Information Sheei and provided Patent 90 and Cf ( was tho primltry insured) pampl$011amp hformllJo inclJdng t full

na E$- datQs ol birth address end social security

numbers Pa1ier 90was admitted arnl later

discharged The wife tlto eeited lh within a few

weeks after Patinl 90s clschage from

PIOVIOEASAN OF COIFiCTOIW (- ) (ACtgtcORREC1-EACT ON SH-U O SE C OSS- COMgtE_ E

IltElEiICNC10 TO THE APPRO FiAT5 lEFCIENC IltEHX PREFIX I

fAG

Continue Phm of Correction Response for Complaint CA0020037$

4 lmpmiddoteme11 rew process for closJre Of B9110 podmiddot by cenca staff members wilhmiddot1 the Emerge cy DeoartmeL t-ew

process requires that prlomiddot to a p00closure all paUenl re a led cocumentatior nor--paient inforrraon sheets wll be p1yscally moved by he aoprcpfiale cerk lc =-oo 3 Which 1s always cccupied by a derical staff nemcer_ Tt-is 1ew processw further safegJard oatie11 hfurmalcn maintained by cmiddotefieal staffWJhin the Errergrocy Departner

Responsible Perton Office Manager

Erlergexy Deoartment

5 Jaily eiiew concucted three times per

day (eacl shift) in a 24-hcur period ro ampW20i0

ensure Cleflos complmnce hilh (on-gorgtg

cepartmeot procedure for scanning and for a periOd

shredding patienl1nformaUon sheeis d 30 C3j5)

Review o continue for a period of 30

days to ensJre 100 compliarce with department procedure Appropriate

acliar to be taken 11 accordance with review lindmgs Review to be re-evaJated after 30 days to ascertalr wheher moniortng will be conllnJeltJ discontinued ot revised

Rl$JgtOO$ibl P8rsQO Office Marbullaer Emergency Department and lead CleO Emergency Department

1i lho

I

81errti0YR3L 1 TITLE (X6)WTE

An defklency ttablmerri erdlgtJ Jib bull - ut IW 11 de a dllfoilttey tkh IM irlllttllbon may boo ud lrorn auwf pmWinl A daiSfTineo trial oltllaquo VlfeJMJIIt proVIde bullIJI)Imiddotenl p m 1M plliefW fotlliiAI9 hciM4 1M fWmgt bullgtwoo AalampqgtJa(IID to dllfi diowig bull dam QligtNuy wlgtelherlaquo rct11 rllill or em _ lllaquoriltkd For lliiiWlP lhit flrntmnamp iillll plmllof regn- ere 4JtimlttgtQ j-4 leloewirll 1t1a date teso doerotfltr ao mado ayenQbe b le aQty_ lf tile an a pill d COIledion s requilamp tn llfued am PifcipampIXfl

I I

I

Slllta-2567 3 ol 5

C OUFORNA HEALTH ANO HUMAN SERVICES AGENCY

DEPARTMENT Of PUBLIC HEALTH

STATpoundlfrNT OF DECLNCiCamp X1) igtRt1 DElJSVPP IltIlltUI tn) IIJLiiPlE CON1illtUC10h 1XJ) WI--pound SUlVEY lhD PtiN OF COfmtiOtJ IOENWC_tT[JN NIJtER GDMPLEXD

A 8UI DNS 050180 I WI G ()eztf2010

NAME OF fPfYJJliR Ult SJPPLfR CRCET ADDkt$$ CiTY gtirt liP CODE John tlulr Medgtta Centermiddot Walnut C--1 Hl01 YGNACIO VALLEY ROAO WALNUT CREEl CA 945913 CONTlA COSTA

Campu COUNTY

(X4) 10 PRF

TA

SIMMAIiJ S ATEMENT OF 0poundFCIHICIpoundS

(EACH CtfiCIfrNCY_IJST Bf lliECl0pound0 flY FLl

RO(iJLJnli Oflt l SC ID(NTI ilfltG ltltfDEW 101

PflEFIX

TAG

Continued FrQm page 2 I hosplal he discovered person was using infonratum to open credit accotrrs make purch01ses nee nOIITeuro The person responsice

1 W S sted aod woo fo nd have i S arre u c

middot DOSsessicn tlCCUTlent the hospital whic

i shlt was usmg to open cp thes e accouns and i I WhiCh was later denb ied as be1rg the Errergency

Deoa ment Pate1 lnformton Sheel

Review on 52010 of te Emergency Depanment middot Paherr lrformallon Sheet Paflent 9051owed

thai 1n nluded Patient 90s pr o ected health

informaNm ircluding rame age gender social

security numoebull address physician account

rmber rredieal recor d nJmber admission date employment statw acd employers address

alw contained 1forna01 about Patient 90 wifeuro i ncludmg helt b name age ma middotta slatus ad ress social seunty nurrber heah

IISoranre mformalon The nciderl Report Form furher showed that le

II Emergency Departmer Pat1errt lormatl01 Sheer

WltS b y registrat101 staff the tene ol

h

pafenrs adnissiof obtain t e nane date of birth address social securit1bull nllmber and insurance informahon aoo it was filled cot by the patient or a family memberlaget of the patient Toe

sheet was lhlt Re9 istmiddota 1gt1 de the middot lnancal COIIIl selor to ente the patients data 1llO i

the hospitals data system a1d was then handed i off to the lead derk who woJk then place it into a

basket that sa directly behind the lead clerks desk I was the le3d clerks job to assure lhe accuracy of the informaton and scan the sheet middotnto

I

Event IOYR3L11 113012010 91044AM

AUORATORY ClilteuroCTORS OR PROVIDEltVSUPPt IER RERESENTAflVIS SONATURE

I

i

Pflt)VDEiiS P _All Of CORECTION

tACM CC ECTIVE 1CIO SHOLJ EIE CROSS

lttTFFEIltCEOTOTHE AP ltOPRltkTii OP CltllCY)

(M)COFlETE

OAE

I

An1 ltlltleiltocy ltgttatement erid -an llllenbullk ( ) derm6$ aerteot which he nnuhn -ay be exltltrod rom eoltecting pUltidwg 41$ ctlt tetmiled lhal olgtOlt sl dllltdgt provide JIIlmml p l on to the IXh tlt Eepl bullor nJUll19 IltOIWl too findbullngs abeyen( yenC sabl 90 dly$ cqwitlJIte date ol survty wgtelercr net a pan m COt 11 ptwltQett FOIIIIffliiG hcrgtet e above hings lld pWamp or 10nectkm ant dillclowble 1 diit5 lcllcwrg u dale hlllil doou nt ant made available kl tte alt IIY If debull-ic gte e11cd an app111red plan rf co-rectioo i roQtii51W c ltltgtnlnued u middotam PAAbullpa cn

lt21 MUL Tl~LE COfSt~uCTiOt

NAME CF PROVIDER Cll SUPPl iEll

--middotmiddotmiddot-------------------------------------------------------------------

CALIFORNIA HEALIH AND HUMAN SERVgtCES AGWCY DEPARTMENT OF PJKIC HEAc rH

S1ATEME1T Dt DEFICIENIf$ (X1l PPcentVDEltSc-PPlEltiClA ( 11 JAT[ SvRVCt iD PIAN OF COltRltTION bullOamphTIbullmiddotCA middotON NWJBER COMLTED

A BUILDING

0501811 B W1NG 1292010

STREET ADORtSS CITY STATE I COD

John Muir Medital CM1er- Walnut Crook 1601 YGNACIO VALLEY ROAD WALNUT CREEK CA 94593 CONTRA COSTA

Campus COUNTY

M IJ SUMIIAIY SlATEAtJH OF lEfiIEIJCfS (l CH OEfiCilNCY MUST bpound FfltrCrrDO flr ltl l RFGcJLATORY OR lSC 0E TIYmiddotNGgt IH MATIOIIJ

Ff10VII)[ S PLAN 7 CCRRECTON f(5) PRU-IX f-C-i COlHftTIIf AOION SHOUlD BE CROSSmiddot COIWLPE

REFEREiCfO TO Hlf AFPROPRIltTf OHICLNC1) OATE

Continued From paglt l

lhe aief1ls rectYd A ccorJmiddotg to he rctdenl i Repcli the ETiergelcy Deparllllerl Patient

nknnallon Shffitl CChid sil in he amp-et for vp lo two days An ED 1ead clerk and a ED t1ansporter

i (staff assigned the duties of transporting patients

withm the hosp ital) W1Ht kwesligaled by the hOspital and found to be relatelt to lgte person

respoiSbe for lle identity heft The mc1dent was

still uider iWestgabon by a police task force

Observation en 6130110 at 10lt30 am_ of he Emergency Departrret the OeSeuroCeuro of ED

Manage showed hree areu ca ed pods tat

Were desk area s wth a glass wall fl 111e front of the

desk Entry to 11e cd area was by way of ar1 open

walkway at e11ner eoo cf the desk Ttere was no

I door cr Pa1ilicn Pod 3 had a desk facing the glass

wall had ccrrpuler termin als and chairs flttCif19 the g la ss wa1 and a co vnter behind the de$1lt with a

basket holding completed admitf1ng papers en It

The EO Manager stated the lead cerk wor ked at

Pod 3

The hospital POlicy tbulltko PHImiddot Pnvacy PrlttciCfls

Uses and DlsclosiES of Proleded 1-ealth

lnformalcn revsed 9G7 aXl lteveWed on 5120110 slated workforce rrem rs (eTiployee vclunteers

ctlleS )lysicans and ohar alliiXl health

professionals whle I)CVdti9 cae may net UStgt or

disclose PHI in a manner bullncotlssten wilh federal

and slate Jaw$ aod regulatons The policy

inslrucieltl staff 10 make sure ttlat medical

middotinformation tat identifies he p atient is ltepl private

i e-cept as the palienl authcnzes or as laws requhlt

IX oermit The p licy further inslvcted

i i

j o

Event iDYRjl11 730200 91044AM

IlTLE (XgtI OATE

Any ooticgtenoy $llemtml ntlmiJ w1gt an a llrw n wnola 11 trlt-middot011Cf whch rte on$ 1 1ion may be excused rom cmrRMg prtWitllt1 middott middot tleettYIIcent tNH omr sttQlt111amp ptevtle $All litgt I gtrJcentCho w h cuen5 Ebullcem lorlvrsig hon1e the 11ndogs abOve Mgt dbull lltgt5 bkl C days llogt9 he daHl

af yen hihl m net a pan Ol ltXWltteJO $ Pf0gt1iW Fw w mg Wflpound lh above londi9 and pillgt$ ol correc ot are chdoSble 14 day hgt hgt9

1-e dale lh e dnttrenb are lldll avulllle tcent tl1$ hlQIIy I deiOiltmC$ are lied an appro ed pa ol WJeeJO $ bulle iJmiddot$ te 10 o IJlaquo prosrgttm

gta1ocopgtUo

73012010

CAUORNIA HFAl TH AND HUMAN SERVICFS AGENCY

DEPARTMENT OF PUBLIC HEAlTH

$ 1TEMfNT JFDEIIt MgtlS XT) PROIiDERISlJPPIIERCL( x Mlltll e CONSRCON pgt) DATE 5UflgtEV

AltD PlAN CF COlllOCgtQgti iOfl lrCATiOt NJIltBFR COoPlffFD A 3JL0iNG

050100 3 WigtC 062912010

N-YF CW OvllER OR SJFPUI STRC - AI)JRESS CrY GT TE l P CODE John Muir Meikll CantO Imiddot Walnut CrQek 1f(l1 YGNACIO V4LLEY ROAD WAlNUT CREEK CA 94598 CONTRA COSTA

CarnpU$ COUNTY

X4)10 PiiEFI

TAG

S t1MARY OnYMIENTO OCFICifN(IES (Efo(li O FCiENbullV IJ$7 IE PRtCEEDED W FL

lfCVATOltr OR lScent llflIFYImiddotKgt NIOilMAlQo

Continued From page 4

Reasolable precaJtb s must be a- en to

rrniMire the chance of inadvertent disdosure of PHI to d1viduals wo tio not have a Jeed lo know middot

iREF X

TAC

PIltOVOERS PLAl OF CCR EC710N

I ACH COR ECtfCACT ON StiOIIU a CROSS-

Rgt(RfNCEO fO THpound 1PPROJgtCIAft OE VfNCY)

15) COJ ETE

Dl1

i

i

I

i

I I

i

Event IDYR3L 11 9 044AM

LAB RATOOY DIRECTORS OR fROvltlERSUfPUER REPRESENTATlVES SIGNAlURE TITLE Zfi) CPTE

Agty dllltcim1q stafemliN(IdiJIg wrh ao ijSem 1bull1 ltlltllfnl a dehrllmcy hdgt hlt in iluten may l8 excu ed I row ccnectm1 proHdlng n m riebummed lhlll o er ampafegusnhi piClt tie gtcJffi ienl prolecboo In te pabllnt_ E=eplorron Jg homgt hefnltfrg above am ltil ble 00 CBJ fuowiCoQ It ltlaW Q trtiJ1 whetter Of IQ a piJin JI orrectlim is wov for nuraing ht11$ 1e lilllole lindlfl91 ltgtd plans o corroctiOf alo lisdosable H aay JulQWill tie dalE lhew docurombullgt are rrade ampva1labW ttl he lacility 1 1ooendes ruq Cliae an tpprQffld p-all ot CllllKl Pn tamp requisill W WIMJCltl progr

ooerocpallttlll

73012010

CAUORNIA HFAl TH AND HUMAN SERVICFS AGENCY

DEPARTMENT OF PUBLIC HEAlTH

$ 1TEMfNT JFDEIIt MgtlS XT) PROIiDERISlJPPIIERCL( x Mlltll e CONSRCON pgt) DATE 5UflgtEV

AltD PlAN CF COlllOCgtQgti iOfl lrCATiOt NJIltBFR COoPlffFD A 3JL0iNG

050100 3 WigtC 062912010

N-YF CW OvllER OR SJFPUI STRC - AI)JRESS CrY GT TE l P CODE John Muir Meikll CantO Imiddot Walnut CrQek 1f(l1 YGNACIO V4LLEY ROAD WAlNUT CREEK CA 94598 CONTRA COSTA

CarnpU$ COUNTY

X4)10 PiiEFI

TAG

S t1MARY OnYMIENTO OCFICifN(IES (Efo(li O FCiENbullV IJ$7 IE PRtCEEDED W FL

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